Working With Clients Experiencing Self-Neglect

Instructor-Led Training

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About the Academy & APSWI

The Academy is a project of San Diego State School of Social Work. Serving over 20,000 health and human services professionals annually, the Academy’s mission is to provide exceptional workforce development and learning experiences for the transformation of individuals, organizations and communities.

APSWI, or Adult Protective Services Workforce Innovations, is a training program of the Academy that provides innovative workforce development to APS professionals and their partners.

ACADEMY PROGRAMS

San Diego State University

Housekeeping

• Schedule for training

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• Encourage all types of communication and participation

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• Content warning

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• Overview of Technology & Breakout Rooms

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Overview of Technology

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Breakout Rooms

• Joining the breakout room:
• Click join
• Asking for Help:
• If you click Ask for Help, it will notify the meeting host that you need assistance and they will be asked to join your breakout room
• Leaving the breakout room:
• You can leave the breakout room and return to the main meeting session at any time
• Click Leave Breakout Room
• Choose if you want to leave the breakout room or the entire meeting.
• When the host ends the breakout rooms, you will be notified and given the option to return to the main room immediately, or in 60 seconds.

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Connection Question

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What is your biggest fear or has been your biggest challenge when working with someone who is experiencing self-neglect?

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Prevalence of Self-Neglect

Learning Objectives

• Define self-neglect, its prevalence, risk factors, and indicators 

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• Assess self-neglect in 5 domains

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• Describe promising techniques for working with adults experiencing self-neglect+

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• Identify safety and risk reduction interventions for adults experiencing self-neglect 

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• Demonstrate an understanding of the elements to document in self-neglect cases

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• Identify community partners to work with in self-neglect cases

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What is Self-Neglect?

• “The negligent failure of an elder or dependent adult to exercise that degree of self care that a reasonable person in a like position would exercise.” - CA W&IC 15610.57 (a)(2), (b)(5), (c)

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• Self-neglect includes but is not limited to the following:
• failure to assist in hygiene or the provision of food, clothing, or shelter,
• failure to provide medical care for physical and mental health needs (does not include a person who voluntarily relies on treatment through spiritual means or prayer alone in lieu of treatment),
• failure to protect from health and safety hazards,
• failure to prevent malnutrition or dehydration,
• substantial inability/failure to manage finances, or
• failure to satisfy any of the above needs due to poor cognitive functioning, mental limitation, substance abuse, or chronic poor health.
• being homeless if the elder or dependent adult is also unable to meet any of the needs specified above

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(Protecting Older Adults from Abuse and Neglect Fact Sheet, 2022)

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�Activity #1 – Case Scenarios��

“An elder or dependent adult’s refusal or failure to perform essential self-care tasks”

• failure to assist in hygiene or the provision of food, clothing, or shelter,
• failure to provide medical care,
• failure to protect from health and safety hazards,
• failure to prevent malnutrition or dehydration,
• inability/failure to manage finances, or
• failure to satisfy any of the above needs due to poor cognitive functioning, mental limitation, substance abuse, or chronic poor health.)
• homelessness

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Activity #2- The Diverse Spectrum�

�Potential Indicators of Self-Neglect�

• Unpaid bills
• Utilities shut off
• Empty refrigerator or spoiled food
• Pest infestation
• Trash piled up
• Poor personal hygiene
• Unorganized or expired medications
• Sudden weight loss
• Frequent falls
• Interior/Exterior home in state of disrepair
• Unmaintained living environment 
• Lack of medical care
• Untreated wounds/sores or dirty bandages
• Lack of assistive medical devices – glasses, hearing aid, walker/cane

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Factors That Could Be Mistaken For or Lead to Self-Neglect 

• Eccentricity

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• Lifestyles that vary from the dominant culture(s)

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• Religious/cultural practices/beliefs

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• Use of alternative medicine or medical practices

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• Trauma

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• Neglect or abuse by others

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• Low Health Literacy

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Health Literacy

• How well a person can get the health information and services that they need, and how well they understand them.
• Using them to make healthier decisions. 

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• Access to information that they can understand

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• Finding information, communicating with health care providers, managing a disease

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• Knowledge of medical words, and of how their health care system works

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(medlineplus.gov/healthliteracy)

Low Health Literacy and Self-Neglect:

• Make more medication or treatment errors. 

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• Are less able to comply with treatments.

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• Lack the skills needed to successfully negotiate the health care system.

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• Are at a higher risk for hospitalization 

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(Villaire, M., 2009)

Clients may try to hide illiteracy/lack of understanding:

• “I forgot my glasses.”

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• “I don’t need to read this now; I’ll read it after you leave.”

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• “I’d like to discuss this with my family.”

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• Nodding (Believe they understand but don’t.)

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Implications of Self-Neglect

• Higher than expected mortality rates  (Dong, et al; Badr, Hossain, & Iqbal, 2005).  
• Hospitalization
• Long-term care placements
• Environmental and safety hazards
• Housing insecurity

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�Ethical issues in Self-neglect��

• Avoid imposing personal values 
• Informed consent
• Least restrictive services
• Rights of Adults:
• Safety
• Civil Rights
• Decision Making
• Right to Refuse

Safety versus Self-Determination

When these interests compete, clients’ right to exercise self-determination outweighs their safety. People have a right to take risks. 

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There are two exceptions:

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• When clients do not understand risks AND the risks or dangers are substantial, involuntary measures may be warranted.

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• Other interventions may be pursued without the consent of the client. 

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��Assessing Self-Neglect in 5 Domains��

Activity #3 - Name the Domain!

• A client consistently is a no-show for dialysis. 

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• A client with Alcohol Use Disorder chooses not to engage in Alcohol Addiction Treatment.

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• A client is lonely and declines offers to engage in community support activities. 

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• A client repeatedly engages in scams and has lost most of their assets. 

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• A client diagnosed with Obsessive Compulsive Disorder is experiencing hoarding behaviors.

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Name the Domain! - continued

• A client with a diagnosis of neurocognitive disorder (NCD) was discharged from the hospital and Home Health was ordered to follow-up with the client at home, but the client refused to let the Home Health nurse into the home.  

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• A client with reduced mobility is unable to keep the home safely maintained.

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• A client needs assistance in many areas and doesn't have a support network to help them.

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• A client on oxygen is forgetful and keeps lighting a cigarette while on oxygen. 

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• A client has forgotten to pay their utilities and there is a water shut-off notice on the front door. 

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Severity and Urgency

URGENCY

Activity #4 – Assessing for Severity and Urgency

1. Each breakout group’s number will correspond with the domain matching that number:
• Domain 1: Physical/Medical Factors
• Domain 2: Psychological/Mental Health
• Domain 3: Environmental
• Domain 4: Financial
• Domain 5: Social and Cultural

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• Imagine that your group is assessing someone who is experiencing self-neglect that primarily falls into your assigned domain.

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• List 3-5 outcomes to the person, support system or others that could happen as a result of the self-neglect in that domain

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• Once listed, the group will then rank these factors based on which you feel are the most severe or urgent and be prepared to explain why.

Assessment Tools

• Self-Neglect Assessment Tool:
• Elder Self-Neglect Assessment (ESNA)

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• Other Decision-Making and Functional Assessment Tools:
• Clock Drawing Tests
• Geriatric Depression Scale (Short Form)
• Confusion Assessment Method
• Lichtenberg Financial Decision Screening Scale
• Memory Impairment Screen
• Montreal Cognitive Assessment
• Mini Mental State Exam
• St. Louis University Mental Status Examination
• Assessment of Capacity for Everyday Decision-Making
• Interview of Decisional Abilities
• The Executive Interview

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Decision-Making Capacity

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• Decision-Making Capacity is the ability to adequately process information in order to make a decision based on that information

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• Task specific- ability to do what?

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• Types of decisions include:
• Medical Consent;
• Sexual Consent;
• Financial;
• Testamentary
• Ability to Live Independently

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Ability

• Live alone safely

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• Provide self care (e.g. eating, bathing, taking medications)

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• Make informed decisions about whether or not to accept medical treatment, health care, or services 

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• Manage finances

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Capacity

�Executive Function��

• Higher-level cognitive skills such as judgment, insight, the ability to plan for the future, and “mental flexibility” (the ability to switch from one mental task to another).

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�Enhancing Decisional Ability�

• Determine if there are times of day when a client performs at his or her best.

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• Make sure that the client is using assistive devices to optimize communication.

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• Get medical work-up

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Developing Questions for Mrs. Green

• In groups, develop questions to assess for Mrs. Green’s ability to make decisions in your assigned focus area (self-care or finances)

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• Remember to ask questions that assess the following:
• Understanding
• Appreciation
• Reasoning
• Expressing Choice

Challenging Factors in Self-Neglect

Multiple challenges can arise when assessing people experiencing self-neglect.

• This is a complex situation.

��Working with Clients who are Hesitant��

�Reasons People May Refuse Help ��

• NCDs  

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• Anxiety

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• Grief

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• Depression

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• Lack of insight

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• Behavioral Health

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• Shame

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• Distrust (of government officials, caregivers, etc.)

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• Fatigue

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• Fear (losing control, added violence, costs involved)

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• Pain

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• Anger

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Hoarding Disorder and Self-Neglect�

Persistent difficulty discarding or parting with possessions, regardless of their actual value.

• Due to a perceived need to save the items and to the distress associated with discarding them.
• Results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, or the authorities).
• Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment safe for oneself or others).
• Not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).

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Feb. 3rd 2018- https://www.mayoclinic.org/diseases-conditions/hoarding-disorder/symptoms-causes/syc-20356056

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�Impact of Compulsive Hoarding��

• Significant distress or impairment in functioning 

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• Reclusiveness

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• Death 

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• Homelessness 

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• Shame and depression

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(Los Angeles Times, June 02, 2016)�

Substance Use Disorder and Self-Neglect

• Substance use disorder can amplify the health and safety risks that already exist in the lives of older adults or adults with disabilities.

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Overview of Available Approaches

• Motivational Interviewing
• Substance Use Treatment
• Hoarding Treatment

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��Motivational Interviewing��

“Motivational interviewing is a directive, client centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.”

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• Motivation to change is elicited from the client (not imposed upon the client).
• The client must resolve their own ambivalence.
• Direct persuasion does not work!
• Your style must be quiet and eliciting while helping the client examine and resolve the ambivalence.
• Readiness to change is the product of the interpersonal interaction.
• You are a partner not “the expert.”

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Rollnick S., & Miller, W.R. (1995). What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334 (http://www.motivationalinterview.org/clinical/whatismi.html).�

��Core Concepts of MI��

• Express empathy
• Ability to share in the feelings of others and put oneself in another’s situation

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• Support self efficacy
• Help them stay motivated. Solutions can change

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• Roll with resistance
• Avoid arguing, encourage creating own solutions

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• Develop discrepancy
• Help develop their discrepancy between current behavior and future goals 

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Motivationalinterviewing.org

Decisional Balance Worksheet��

motivationalinterviewing.org

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�Substance Use Disorder Treatment��

• Hospital Detox

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• Medication and Therapy

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• Counseling

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• Self Help groups or Peer Support

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• Harm Reduction

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Treatment for Hoarding

• Forced clean-ups DON’T work for long-term solutions!

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• Research is still pending:
• Cognitive-Behavioral Therapy
• Medications
• Support groups
• Harm Reduction

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Interventions For Those Experiencing Self-Neglect

What factors determine appropriate interventions?

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Types of Intervention

Support Services

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Involuntary Interventions

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Mental Health Treatment

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Social Support/ Supportive Services

• Support for caregivers

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• Caregiver services

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• Daily money management

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• Friendly visitors

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• Telephone Reassurance

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• Lifeline

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Mental Health Treatment�

• Crisis intervention

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• Individual or group counseling for anxiety, depression, substance use, traumatic stress, hoarding, grief

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• Medications

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Involuntary Interventions��

• Involuntary assessments or hospitalizations 

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• Protective Custody 

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• Appointment of Representative

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• Probate guardianship or conservatorship of person and/or finances

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• Mental health guardianship or conservatorship of person and/or estate

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• Appointment of a representative payee

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• “Activating” of advance directives

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• Removal of animals by Animal Care and Control Workers

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• Health and Safety regulations

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Activity- Working with Someone Experiencing Self-Neglect

Considering everything covered so far: definitions, indicators, decision-making ability, right to self-determination, various treatment, interventions and resources, answer the following questions in your groups:

• What should the APS professional take into consideration?
• What should they do next?
• What additional information should they gather?
• What interventions or techniques might be helpful?

Importance of Good Documentation

• Continuity of care

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• Provides a baseline for detecting gradual changes

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• May be needed in various legal proceedings

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Partners When Working With People Experiencing Self-Neglect�

• With whom can you partner with?

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��Review: Learning Objectives��

• Define self-neglect, its prevalence, risk factors, and indicators 
• Assess self-neglect in the 5 domains
• Describe promising techniques for working with adults who are self-neglecting, such as ‘Harm Reduction’, and ‘Hoarding Treatment’
• Identify safety and risk reduction interventions for adults who are self-neglecting 
• Demonstrate an understanding of the elements to document in self-neglect cases
• Identify community partners to work with in self-neglect cases

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Please Complete Your Evaluations

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Thank You!